PLOS ONE

RESEARCH ARTICLE

Ten-years cardiovascular risk among

Bangladeshi population using non-laboratory-
based risk chart of the World Health
Organization: Findings from a nationally
representative survey
Abu Abdullah Mohammad Hanif ID1, Mehedi Hasan ID1, Md Showkat Ali Khan1, Md.
Mokbul Hossain1, Abu Ahmed Shamim1, Moyazzam Hossaine1, Mohammad Aman Ullah2,
Samir Kanti Sarker2, S. M Mustafizur Rahman2, Md Mofijul Islam Bulbul2, Dipak
a1111111111
Kumar Mitra3, Malay Kanti Mridha1*
a1111111111
a1111111111 1 Centre for Non-Communicable Diseases and Nutrition, BRAC James P Grant School of Public Health,
a1111111111 BRAC University, Dhaka, Bangladesh, 2 National Nutrition Services (NNS), Institute of Public Health Nutrition
a1111111111 (IPHN), Dhaka, Bangladesh, 3 North-South University, Dhaka, Bangladesh

* malay.mridha@bracu.ac.bd

OPEN ACCESS Abstract

Citation: Hanif AAM, Hasan M, Khan MSA, Hossain
The World Health Organization (WHO) has recently developed a non-laboratory based cardio-
M.M, Shamim AA, Hossaine M, et al. (2021) Ten-
years cardiovascular risk among Bangladeshi vascular disease (CVD) risk chart considering the parameters age, sex, current smoking sta-
population using non-laboratory-based risk chart tus, systolic blood pressure, and body mass index. Using the chart, we estimated the 10-years
of the World Health Organization: Findings from a CVD risk among the Bangladeshi population aged 40–74 years. We analyzed data from a
nationally representative survey. PLoS ONE 16(5):
nationally representative survey conducted in 2018–19. The survey enrolled participants from
e0251967. https://doi.org/10.1371/journal.
pone.0251967 82 clusters (57 rural, 15 non-slum urban, and 10 slums) selected by multistage cluster sam-
pling. Using the non-laboratory-based CVD risk chart of the World Health Organization (WHO),
Editor: Giuseppe Vergaro, Fondazione Toscana
Gabriele Monasterio & Scuola Superiore we categorized the participants into 5 risk groups: very low (<5%), low (5% to <10%), moderate
Sant’Anna, ITALY (10% to <20%), high (20% to <30%) and very high (> = 30%) risk. We performed descriptive
Received: April 8, 2020 analyses to report the distribution of CVD risk and carried out univariable and multivariable
logistic regression to identify factors associated with elevated CVD risk (> = 10% CVD risk). Of
Accepted: May 6, 2021
the 7,381 participants, 46.0% were female. The median age (IQR) was 59.0 (48.0–64.7) years.
Published: May 26, 2021
Overall, the prevalence of very low, low, moderate, high, and very high CVD risk was 34.7%,
Peer Review History: PLOS recognizes the 37.8%, 25.9%, 1.6%, and 0.1%, respectively. Elevated CVD risk (> = 10%) was associated
benefits of transparency in the peer review
with poor education, currently unmarried, insufficient physical inactivity, smokeless tobacco
process; therefore, we enable the publication of
all of the content of peer review and author use, and self-reported diabetes in both sexes, higher household income, and higher sedentary
responses alongside final, published articles. The time among males, and slum-dwelling and non-Muslim religions among females. One in every
editorial history of this article is available here:
four Bangladeshi adults had elevated levels of CVD risk, and males are at higher risk of occur-
https://doi.org/10.1371/journal.pone.0251967
ring CVD events. Non-laboratory-based risk prediction charts can be effectively used in low
Copyright: © 2021 Hanif et al. This is an open
resource settings. The government of Bangladesh and other developing countries should train
access article distributed under the terms of the
Creative Commons Attribution License, which the primary health care workers on the use of WHO non-laboratory-based CVD risk charts,
permits unrestricted use, distribution, and especially in settings where laboratory tests are not available.
reproduction in any medium, provided the original
author and source are credited.

PLOS ONE | https://doi.org/10.1371/journal.pone.0251967 May 26, 2021 1 / 17

PLOS ONE
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
files.
Funding: The study was funded by the National
Nutrition Services (NNS), Institute of Public Health
Nutrition, Ministry of Health and Family Welfare,
Government of Bangladesh. Besides, salaries and
administrative support for some of authors came
from the National Institute for Health Research
(NIHR) (16/136/68) using UK aid from the UK
Government to support global health research, and
by Wellcome Trust (212945/Z/18/Z). The views
expressed in this publication are those of the
author(s) and not necessarily those of the NIHR or
the UK Department of Health and Social Care.
Competing interests: Some of the representatives
of the Ministry of Health and Family Welfare, who
approved the funding of the study were involved
with the Technical Advisory Group. Though they
had opinions about some maternal and child health
and nutrition indicators, they did not have any role
in the design, conduct, data analysis, and
manuscript writing of the adolescent component of
the study. However, this does not alter our
adherence to PLOS ONE policies on sharing data
and materials.
PLOS ONE | https://doi.org/10.1371/journal.pone.0251967 May 26, 2021
Cardiovascular disease risk among the Bangladeshi population
Introduction
The world has been experiencing a massive burden of noncommunicable diseases (NCD) for
the last few decades, and the trend is steadily upward. Noncommunicable diseases (NCDs)
claim a total of 41 million lives every year, which is equivalent to 71% of all global deaths [1].
About 37% of these deaths occur between the ages of 30 and 69 years, and 85% of these prema-
ture deaths occur in low and middle-income countries [1]. Among the NCDs, cardiovascular
diseases (CVD) such as coronary heart diseases and stroke are most common and were respon-
sible for an estimated 17�8 million deaths in 2017, and 75% of these deaths were in the low-
income and middle-income countries [2]. In 2040, eight of the top ten causes of death world-
wide will be NCDs with coronary heart diseases, and stroke will continue to be in the first and
the second places, respectively [3]. South Asia has the highest total burden of CVD partly due to
its massive population size and early onset of CVD in this population [4]. Between 1990 and
2010, there was a 73% increase in the years of life lost in the South Asian region, compared to a
30% global increase in the same period due to CVDs [5]. In Bangladesh, NCDs are responsible
for 67% of all deaths; and an estimated 30% of the total deaths are caused by CVDs [6].
CVD is an umbrella term coined for conditions affecting the heart or blood vessels. CVD
causes arterial damage in the major organs such as the brain, heart, kidney, and eyes [7]. How-
ever, most CVDs are preventable (through addressing the) modifiable risk factors; through
reducing or preventing behavioral risk factors such as smoking and smokeless tobacco use,
unhealthy diet, insufficient physical activity, overweight, and obesity [8]. One way to reduce
the burden of CVDs is to identify people with the risk of developing CVDs due to hyperten-
sion, diabetes, dyslipidemia, and implementing appropriate management protocols [1].
Assessment of CVD risk based on multiple risk factors rather than individual risk factors
brings more accuracy and allows cost-effective management and treatment of CVD [9].
In 2019, the World Health Organization (WHO) revised the 2007 CVD risk chart with the
help of a risk-chart working committee using data from 21 global regions [10]. The committee
revised the two previous laboratory-based charts and proposed a new non-laboratory-based
chart. The WHO Laboratory-based CVD risk assessment chart predicts the 10-years risk of
fatal or non-fatal CVD events using data on age, sex, smoking status, systolic blood pressure,
and total serum cholesterol, along with the history of diabetes. The WHO non-laboratory-
based CVD risk chart was designed for resource-poor settings. This chart predicts ten-years
CVD risk using the information on age, sex, smoking status, systolic blood pressure, and body
mass index. Bangladesh has recently incorporated these revised CVD risk charts in its ‘NCD
management protocol’ and has started training the primary health care workers [11]. However,
as the laboratory-based charts need data on blood sugar and total serum cholesterol, the use of
the laboratory-based charts can be impossible in settings where these tests are unavailable.
Therefore, in resource-poor settings, the non-laboratory-based chart can help the health care
workers in screening, primary management, counseling, and referral of the patients at risk of
CVD. However, there is a lack of nationally representative data on the prevalence of ten-years
CVD risk in Bangladesh. In this study, we aimed to assess the prevalence of ten-years CVD
risk among the 40–74 years old population of Bangladesh using the non-laboratory-based
CVD risk assessment of the WHO. Our study will help the government to plan specific NCD
interventions targeted to people at different risk levels of CVD.
Materials and methods
Study design and site
The government of Bangladesh has been implementing the Food Security and Nutrition Sur-
veillance Project (FSNSP) among women and children since 1990 [12]. In the 2018–19 round
2 / 17
PLOS ONE Cardiovascular disease risk among the Bangladeshi population

of this surveillance, we included other population groups, e.g., adolescent boys and girls, adult
males, and elderly people. The FSNSP is aimed to generate nationally and divisionally repre-
sentative estimates of various nutritional and health-related variables. The 2018–2019 round
was conducted between October 2018 and October 2019. In this round, we enrolled partici-
pants from rural, non-slum urban, and slum areas in all eight administrative divisions of Ban-
gladesh. We enrolled in study participants from 82 randomly selected clusters (57 rural, 15
non-slums urban, and 10 slums) from all over Bangladesh. In the main survey, we enrolled
participants from six age groups: children (0 to <5 years), adolescent girls (10–19 years), ado-
lescent boys (10–19 years), adult women (20–59 years), adult men (20–59 years) and elderly
people (60 years and above).

Sample size and sampling techniques

We used a multistage cluster sampling to determine the sample size for the selected indicators
with prevalence (p) ranged from 4% to 98% to generate national and divisional estimates. Con-
sidering the type I error, α = 0.05; allowable margin of error, d = 0.05 (or d = p/2 if p � 0.1);
design effect, DEF = 1.61, we calculated a sample size of 62 individuals from each cluster for
each age group.
We selected the study sites in rural, urban, and slum areas applying different sampling tech-
niques. For rural areas, we randomly selected two districts from each of the divisions as the
first stage of the multistage sampling, and from each of the selected districts, we chose one
sub-districts. We then selected two unions (smallest administrative units of Bangladesh) from
each of the selected sub-districts. After consulting with the local government officials, the field
coordinator identified and mapped the villages/mouzas/geographically demarcated segments
with 250–400 households in the selected unions. Finally, we randomly chose two of the listed
village/mouza/segments from each union as the study clusters.
In the non-slum urban areas, we used the population proportion of the Bangladesh Bureau
of Statistics (BBS) 2011 census to select the required study clusters [13]. We randomly selected
15 wards (1–2 wards/division) from the city corporations. The field coordinator identified and
mapped the Mahalla (similar to the villages) with more than 250 households. They further sub-
divided the mahallas with >500 households into smaller geographically defined segments of
~250 households. We randomly selected one segment from each of the selected wards as the
non-slum urban clusters.
In the slum areas, we took guidance from the Census of Slum Areas and Floating Popula-
tion 2014 to select the study clusters [14]. The field coordinator identified and mapped the
slums with �300 households and further sub-divided the slums with >500 households into
smaller segments. We then randomly selected two segments or slums from the Dhaka and
Chattogram division and one from each of the other six divisions as the slum study clusters.
For each cluster, research assistants first listed all households and their members according
to the age groups. If any household had more than one person of a specific age group, we ran-
domly selected one member of that age group from that household and thus came up with a
sampling frame for that cluster. A statistician then selected 80 individuals from the list using
Simple Random Sampling to enroll 62 participants from each age group from a cluster.

Data collection and measurements

Five data collection teams—each comprised of 4–5 Research Assistants (RA) and one Project
Officer (PO) were deployed for data collection. We used a structured questionnaire, developed
initially in English and later translated into Bengali, to collect the data using face-to-face inter-
views. RAs directly entered all the data from face-to-face interviews and physical

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

measurements into the tablet computers (Samsung Galaxy Tab A7) using a customized Sur-
veyCTO application [Dobility, Inc.]. They uploaded all the collected data to the server at the
end of the day. We measured height (using a locally made portable stadiometer), weight (using
TANITA UM-070 weighing scale), waist circumference (using measuring tape), and blood
pressure (using Omron HEM 7120) of the study participants. As specified in the Food and
Nutrition Technical Assistance (FANTA) anthropometry manual, the WHO guideline was fol-
lowed to take anthropometric measurements [15]. We measured the weight to the nearest 0.1
kg and the height to the nearest 0.1 cm. Waist circumference was measured to the nearest 0.1
cm. RAs took two measurements of weight, height, and waist circumference. If the difference
between the first two measurements were >0.1 kg for weight and >0.5 cm for height and waist
circumference, they took the third measurement. RAs ensured that the study participant was
resting for at least 15 minutes before taking blood pressure, and a three minutes interval was
programmed between two subsequent blood pressure readings. We instructed the research
assistants to take a third measurement only if the difference between the first two measure-
ments was �10 mmHg for systolic and/or diastolic blood pressure.

The WHO cardiovascular diseases risk charts

We used the WHO non-laboratory-based CVD risk chart developed for 5 south Asian coun-
tries (Bangladesh, Bhutan, Nepal, India, and Pakistan) to estimate the risk of fatal or non-fatal
cardiovascular events, such as myocardial infarction and stroke in ten years period [10]. In
2019, the WHO CVD risk charts working group constructed this chart for the resource-poor
settings and revised the previous laboratory-based charts [10]. The parameters used in the risk
algorithm of the non-laboratory-based chart were age (in years), sex (male vs. female), smok-
ing status (no vs. yes), body mass index (BMI) as weight in kg divided by height in squared-
meter, and systolic blood pressure (SBP) in mmHg. Although this chart can provide the exact
risk score of individuals aged 40 to 74 years, it can also stratify the people of this age group into
six groups based on the calculated risk score–very low risk (<5%), low risk (5% to <10%),
moderate risk (10% to <20%), high risk (20% to <30%) and very high risk (�30%) to imple-
ment different management protocols [16].

Explanatory variables
We defined the outcome variable as elevated CVD risk if the total CVD risk score was �10%
and lower CVD risk if the risk score was <10%. We listed the potential factors associated with
elevated CVD risk (CVD risk �10%) among the population of Bangladesh based on literature
review and considering data availability from this survey. The sociodemographic variables
included the place of residence (rural, non-slum urban, and slum), education (no formal edu-
cation, up to 5 years, up to 10 years and >10 years), household income, marital status (cur-
rently married vs. never married or divorced or widowed or separated), and religion (Muslim
vs. non-Muslims). Among the behavioral variables were physical activity, sedentary time (0 to
240 minutes/241 to 360 minutes/>360 minutes), fruits and vegetable consumption (�5 serv-
ings/day vs. <5 servings), and smokeless tobacco consumption status (no vs. yes). We consid-
ered a person physically active (during work, transport, and recreational activities) if he or she
reported at least 150 minutes of moderate-intensity physical activity per week or 75 minutes of
vigorous physical activity per week or equivalent [17]. Self-reported diabetes and waist circum-
ference were the clinical and anthropometric and factors. Central obesity was defined as the
waist circumference of �90 cm in males and �80 cm in females [18]. For this analysis, we con-
sidered the mean of the two closest measurements of all anthropometric variables and blood

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

pressure. Self-reported diabetes was recorded if any respondent reported that a trained health
care provider ever told him or her that he or she had diabetes.

Quality assurance and control

We provided extensive training to the RAs and the POs on data collection, physical measure-
ments, as well as calibration and maintenance of data collection instruments. We also orga-
nized standardization sessions to check the readiness of the RAs for data collection activities.
We field-tested the questionnaire, modified it, and refreshed the RA and POs based on the
feedback from the field testing. The POs directly observed 5% of the interviews and re-inter-
viewed another 5% of the randomly selected study participants within 48 hours of the initial
interview to ensure data quality. We also performed interim analyses to check the data quality.
The RAs routinely calibrated the data collection instruments.

Statistical analysis
We performed all the data management, cleaning, and analysis using Stata 15.1 (Stata Corp,
College Station, TX, USA) [19]. All the characteristics of the study participants in this analysis
were reported as categorical variables. As the males and females differed by the distribution of
cardiovascular disease risk, we carried out univariable and multivariable logistic regression
analysis to identify the factors associated with an elevated level of CVD risk separately for both
sexes. We imputed missing values for the variables sedentary time (6.9%), body mass index
(1.2%), systolic blood pressure (0.2%), diastolic blood pressure (0.2%) using the Hot-Deck
method to include the cases as much as possible [20]. We calculated the CVD risk score
according to the non-laboratory-based WHO CVD risk chart 2019 [10]. We performed
descriptive analyses to report the background characteristics of the study population and the
distribution of the CVD risk levels across the strata of the background characteristics. We then
carried out univariable logistic regression to see the association of the elevated CVD risk
(� 10%) with the explanatory variables. However, we did not include age, sex, smoking status,
body mass index, and hypertension in the univariable or multivariable analyses as those were
used as the variables in the WHO CVD risk chart to calculate CVD risk. The multivariable
logistic regression analysis was conducted with the variables with a p-value of �0.2 in the uni-
variable logistics regression analysis [21]. Variance inflation factors (VIFs) were checked to
assess multi-collinearity among variables. We reported crude and adjusted odds ratios with
95% confidence intervals and considered the factors statistically significant if the p-value was
<0.05. Besides analyses with imputed missing values, we also performed complete case analy-
sis and provided the results as S1 and S2 Tables.

Ethical considerations
The Institutional Review Board (IRB) of the BRAC James P Grant School of Public Health,
BRAC University, Dhaka, Bangladesh, provided the ethical approval of the FSNSP 2018–19
(IRB Reference number: 2018-020-IR). The research assistants obtained written informed con-
sent from the respondents before data collection and measurements. The field coordinators
met the community leaders and discussed the study purpose and procedure to ensure commu-
nity consent.

Results
We enrolled 30,003 participants of 6 different age groups from 17,323 households. For this
analysis, we extracted data of 7,757 males and females aged from 40 years to 74 years, as the

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Fig 1. Diagram showing the process of extracting eligible participants.

https://doi.org/10.1371/journal.pone.0251967.g001

WHO CVD risk chart is only applicable for this age group. We then dropped 376 participants
who had a known history of CVD events (e.g., stroke), which provided us a sample size of
7,381 participants for CVD risk assessment using the WHO non-laboratory-based chart. Of
the respondents, 3,429 (46%) were female. Fig 1 demonstrates how we extracted 7,381 partici-
pants eligible for the CVD risk assessment algorithm from the entire study population.
Table 1 describes some key sociodemographic, behavioral, and biological characteristics of
the study participants. The median age with interquartile range was 58.6 (48.1–64.6) years and
60.2 (48.0–64.8) years for males and females, respectively. About three-fourths of the partici-
pants were from rural areas. About half of the males (45%) and about two-thirds of the females
(66%) had no formal education. While 97% of the males were currently married, about half of
the women (43%) were either divorced, separated, widowed, or never married at the time of
the interview. Islam was the religion of 85% of the respondents. Insufficient physical activity
was reported by 28% of the participants, whereas 88% reported inadequate consumption of

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Table 1. Sociodemographic, behavioral and biological characteristics of the study participants by sex.
Overall (N = 7,381) Male (N = 3,952) Female (N = 3,429) P-value (Chi^2)��
� � �
n (%) n (%) n (%)
Age groups (years) 0.011
40–49 2,278 (30.9) 1,219 (30.8) 1,059 (30.9)
50–59 1,436 (19.5) 818 (20.7) 618 (18.0)
60–69 3,009 (40.8) 1,587 (40.2) 1,422 (41.5)
70–74 658 (8.9) 328 (8.3) 330 (9.6)
Place of residence 0.061
Rural 5,355 (72.6) 2,908 (73.6) 2,447 (71.4)
Non-slum urban 1,226 (16.6) 643 (16.3) 583 (17.0)
Slum 800 (10.8) 401 (10.1) 399 (11.6)
Educational status <0.001
No formal education 4,024 (54.5) 1,771 (44.8) 2,253 (65.7)
1–5 years 935 (12.7) 541 (13.7) 394 (11.5)
6–10 years 1,601 (21.7) 1,006 (25.5) 595 (17.4)
>10 years 821 (11.1) 634 (16.0) 187 (5.5)
Household income <0.001
Lowest (Q1) 1,705 (23.1) 811 (20.5) 894 (26.1)
Lower (Q2) 1,453 (19.7) 800 (20.2) 653 (19.0)
Middle (Q3) 1,727 (23.4) 964 (24.4) 763 (22.3)
Higher (Q4) 1,049 (14.2) 604 (15.3) 445 (13.0)
Highest(Q5) 1,446 (19.6) 772 (19.5) 674 (19.7)
Marital Status <0.001
Currently married 5,760 (78.0) 3,818 (96.6) 1,942 (56.6)
Others£ 1,621 (22.0) 134 (3.4) 1,487 (43.4)
Religion 0.81
Muslim 6,276 (85.0) 3,364 (85.1) 2,912 (84.9)
Others££ 1,105 (15.0) 588 (14.9) 517 (15.1)
Physical Activity 0.009
> = 150 Minutes/week 5,295 (71.7) 2,785 (70.5) 2,510 (73.2)
<150 Minutes/week 2,086 (28.3) 1,167 (29.5) 919 (26.8)
Sedentary time per day <0.001
< = 240 minutes 2,721 (36.9) 1,528 (38.7) 1,193 (34.8)
241 to 360 minutes 2,381 (32.3) 1,175 (29.7) 1,206 (35.2)
>360 minutes 2,279 (30.9) 1,249 (31.6) 1,030 (30.0)
Fruits & Vegetables Consumption <0.001
> = 5 servings/day 913 (12.4) 606 (15.3) 307 (9.0)
<5 servings/day 6,468 (87.6) 3,346 (84.7) 3,122 (91.0)
Current smoker <0.001
No 5,538 (75.0) 2,179 (55.1) 3,359 (98.0)
Yes 1,843 (25.0) 1,773 (44.9) 70 (2.0)
Current smokeless tobacco user <0.001
No 4,138 (56.1) 2,491 (63.0) 1,647 (48.0)
Yes 3,243 (43.9) 1,461 (37.0) 1,782 (52.0)
Self-reported diabetes <0.001
No 6,636 (89.9) 3,632 (91.9) 3,004 (87.6)
Yes 745 (10.1) 320 (8.1) 425 (12.4)
Hypertension <0.001
(Continued )

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Table 1. (Continued)

Overall (N = 7,381) Male (N = 3,952) Female (N = 3,429) P-value (Chi^2)��

� � �
n (%) n (%) n (%)
No 4,456 (60.4) 2,659 (67.3) 1,797 (52.5)
Yes 2,917 (39.6) 1,292 (32.7) 1,625 (47.5)
Body Mass Index (BMI) <0.001
Normal 3,203 (43.8) 1,881 (47.9) 1,322 (39.0)
Underweight 1,300 (17.8) 739 (18.8) 561 (16.6)
Overweight 2,053 (28.1) 1,053 (26.8) 1,000 (29.5)
Obese 761 (10.4) 257 (6.5) 504 (14.9)
Waist Circumference <0.001
Male: <90 cm/ Female: <80 cm 4,744 (64.6) 2,998 (76.1) 1,746 (51.2)
Male: > = 90 cm/ Female: > = 80 cm 2,605 (35.4) 941 (23.9) 1,664 (48.8)
�
Column percentage
��
Chi^2 test between sex and the listed characteristics of the study participants.
£
Never married, widows, divorced and separated.
££
Hindu, Christian, Buddhist and others.

https://doi.org/10.1371/journal.pone.0251967.t001

fruits and vegetables. About 31% of the participants spent at least six hours on a typical day,
either sitting or reclining (other than sleep). Among the participants, 45% of the males and 2%
of females reported as current smokers, whereas 37% of males and 52% of females reported as
current users of smokeless tobacco. About one-third of the males (33%) and half of the females
(48%) were hypertensive, while 8% of males and 12% of females had a history of diabetes. We
did not find much difference between the males and females regarding the prevalence of
underweight (19% vs. 17%) and overweight (27% vs. 30%). However, the prevalence of obesity
among females was two-times higher than their male counterparts (15% vs. 7%).
Overall, the prevalence of very low, low, moderate, high, and very high CVD risk was
34.7%, 37.8%, 25.9%, 1.6%, and 0.1%, respectively. Moreover, the proportion of participants
with moderate to very high CVD risk (henceforth ‘elevated CVD risk’ with a risk score �10%)
was 33.7%, 20.4%, and 27.5% among the males, females, and both sexes, respectively. Table 2
provides the distribution of 10-years CVD risk according to the sociodemographic and other
background characteristics. The proportion of participants with elevated CVD risk was higher
among advanced age groups. For example, only 0.4% of the persons aged 40–49 years had ele-
vated CVD risk, whereas the proportion of the same was 7.3% in 50–59 years, 41.9% in 60–69
years, and 100% among those aged 70+ years. Males, unmarried (never married, divorced,
widowed, separated), non-slum urban residents, and the non-Muslims had a higher prevalence
of elevated CVD risk compared to females, currently married, rural/slum residents, and Mus-
lims, respectively. Fig 2 visualizes the pattern of the prevalence of elevated CVD risk, i.e., risk
�10% by sex and age of the participants.
Tables 3 and 4 report univariable and multivariable logistic regression results for males and
females, respectively. In univariable regression for males, higher household income, being
unmarried (never married, divorced, widowed, separated), insufficient physical activity, more
sedentary time, inadequate intake of fruits and vegetable, being a smokeless tobacco user, hav-
ing self-reported diabetes, and higher waist circumference was positively associated with ele-
vated CVD risk, whereas in females, all those factors except higher waist circumference were
positively associated with an elevated level of CVD risk. However, in the multivariable logistic
regression analysis, being unmarried (never married, divorced, widowed, separated),

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Table 2. Distribution of 10-years risk of fatal or non-fatal cardiovascular risk, according to background characteristics.
Variables Very low to low (<10%) Moderate (�10% to <20%) High to very high (�20%) P-value (Chi^2)��
� � �
n (%) n (%) n (%)
Overall 5,351 (72.5) 1,908 (25.9) 122 (1.7)
Sex <0.001
Male 2,621 (66.3) 1,236 (31.3) 95 (2.4)
Female 2,730 (79.6) 672 (19.6) 27 (0.8)
Age groups (years) <0.001
40–49 2,270 (99.7) 8 (0.4) 0 (0.0)
50–59 1,331 (92.7) 103 (7.2) 2 (0.1)
60–69 1,750 (58.2) 1,220 (40.6) 39 (1.3)
70–74 0 (0.0) 577 (87.7) 81 (12.3)
Place of residence 0.324
Rural 3,904 (72.9) 1,359 (25.4) 92 (1.7)
Non-slum urban 863 (70.4) 346 (28.2) 17 (1.4)
Slum 584 (73.0) 203 (25.4) 13 (1.6)
Educational status 0.321
No formal education 2,874 (71.4) 1,083 (26.9) 67 (1.7)
1–5 years 689 (73.7) 229 (24.5) 17 (1.8)
6–10 years 1,187 (74.1) 392 (24.5) 22 (1.4)
>10 years 601 (73.2) 204 (24.9) 16 (2.0)
Household income 0.032
Lowest (Q1) 1,296 (76.0) 385 (22.6) 24 (1.4)
Lower (Q2) 1,040 (71.6) 384 (26.4) 29 (2.0)
Middle (Q3) 1,254 (72.6) 444 (25.7) 29 (1.7)
Higher (Q4) 739 (70.5) 294 (28.0) 16 (1.5)
Highest(Q5) 1,022 (70.7) 400 (27.7) 24 (1.7)
Marital Status <0.001
Currently married 4,327 (75.1) 1,346 (23.4) 87 (1.5)
Others£ 1,024 (63.2) 562 (34.7) 35 (2.2)
Religion 0.097
Muslim 4,577 (73.0) 1,600 (25.5) 99 (1.6)
Others££ 774 (70.1) 308 (27.9) 23 (2.1)
Physical Activity <0.001
> = 150 Minutes/week 4,107 (77.6) 1128 (21.3) 60 (1.1)
<150 Minutes/week 1,244 (59.6) 780 (37.4) 62 (3.0)
Sedentary time per day <0.001
< = 240 minutes 2,097 (77.1) 594 (21.8) 30 (1.1)
241 to 360 minutes 1,705 (71.6) 633 (26.6) 43 (1.8)
>360 minutes 1,549 (68.0) 681 (29.9) 49 (2.2)
Fruits & Vegetables Consumption 0.148
> = 5 servings/day 685 (75.0) 212 (23.2) 16 (1.8)
<5 servings/day 4,666 (72.1) 1,696 (26.2) 106 (1.6)
Current smoker <0.001
No 4,262 (77.0) 1,222 (22.1) 54 (1.0)
Yes 1,089 (59.1) 686 (37.2) 68 (3.7)
Current smokeless tobacco user 0.178
No 3,035 (73.3) 1,036 (25.0) 67 (1.6)
Yes 2,316 (71.4) 872 (26.9) 55 (1.7)
(Continued )

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Table 2. (Continued)

Variables Very low to low (<10%) Moderate (�10% to <20%) High to very high (�20%) P-value (Chi^2)��
� � �
n (%) n (%) n (%)
Self-reported diabetes <0.001
No 4,862 (73.3) 1,663 (25.1) 111 (1.7)
Yes 489 (65.6) 245 (32.9) 11 (1.5)
Hypertension <0.001
No 3,650 (81.9) 804 (18.0) 2 (0.0)
Yes 1694 (58.1) 1,103 (37.8) 120 (4.1)
Body Mass Index (BMI) 0.042
Normal 2,299 (71.8) 856 (26.7) 48 (1.5)
Underweight 930 (71.5) 347 (26.7) 23 (1.8)
Overweight 1,515 (73.8) 500 (24.4) 38 (1.9)
Obese 587 (77.1) 165 (21.7) 9 (1.2)
Waist Circumference 0.129
Male: <90 cm/ Female: <80 cm 3,430 (72.3) 1,243 (26.2) 71 (1.5)
Male: > = 90 cm/ Female: > = 80 cm 1,910 (73.3) 644 (24.7) 51 (2.0)
�
Row percentage
��
Chi^2 test between risk categories and the listed characteristics of the study participants.
£
Never married, widows, divorced and separated.
££
Hindu, Christian, Buddhist and others except Muslims.

https://doi.org/10.1371/journal.pone.0251967.t002

insufficient physical activity, smokeless tobacco use and having self-reported diabetes in both
sexes; higher household income and higher sedentary time among only males; and being slum
dwellers and non-Muslim among only females were positively associated with elevated CVD

Fig 2. The prevalence of elevated CVD risk (CVD risk �10%) by sex and age of the participants.
https://doi.org/10.1371/journal.pone.0251967.g002

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Table 3. Univariable and multivariable logistic regression results with potential determinants of elevated CVD risk �10% (for males)� .
Variables Univariable Logistic Regression Multivariable Logistic Regression��
COR 95% CI P value AOR 95% CI P-value
Place of residence
Rural Ref Ref
Non-slum urban 1.03 0.86, 1.23 0.771 NA NA NA
Slum 1.06 0.85, 1.31 0.632 NA NA NA
Educational status
No formal education Ref Ref
1–5 years 0.96 0.78, 1.18 0.705 0.89 0.72, 1.09 0.258
6–10 years 0.89 0.75, 1.04 0.150 0.79 0.66, 0.94 0.007
>10 years 0.89 0.74, 1.08 0.244 0.62 0.50, 0.78 <0.001
Household income
Lowest (Q1) Ref Ref
Lower (Q2) 1.18 0.95, 1.45 0.128 1.17 0.95, 1.45 0.144
Middle (Q3) 1.04 0.85, 1.28 0.692 1.09 0.88, 1.34 0.435
Higher (Q4) 1.35 1.08, 1.68 0.009 1.34 1.06, 1.69 0.013
Highest(Q5) 1.34 1.08, 1.65 0.007 1.33 1.06, 1.67 0.013
Marital Status
Currently married Ref Ref
Others��� 3.14 2.21, 4.47 <0.001 2.88 2.00, 4.14 <0.001
Religion
Muslim Ref Ref
Others���� 1.09 0.91, 1.31 0.346 NA NA NA
Physical Activity
> = 150 Minutes/week Ref Ref
<150 Minutes/week 1.92 1.66, 2.21 <0.001 1.77 1.52, 2.07 <0.001
Sedentary time per day
< = 240 minutes Ref Ref
241 to 360 minutes 1.47 1.25, 1.72 <0.001 1.34 1.13, 1.58 0.001
>360 minutes 1.50 1.27, 1.75 <0.001 1.20 1.01, 1.43 0.035
Fruits & Vegetables Consumption
> = 5 servings/day Ref Ref
<5 servings/day 1.21 1.00, 1.46 0.049 1.06 0.87, 1.28 0.570
Current smokeless tobacco user
No Ref Ref
Yes 1.18 1.03, 1.36 0.015 1.21 1.06, 1.40 0.007
Self-reported diabetes
No Ref Ref
Yes 1.66 1.32, 2.09 <0.001 1.55 1.21, 1.98 0.001
Waist Circumference
Male: <90 cm/ Female: <80 cm Ref Ref
Male: > = 90 cm/ Female: > = 80 cm 1.26 1.09, 1.47 0.003 1.15 0.97, 1.36 0.110
�
The regression analysis outcome was elevated CVD risk (risk of CVD events in 10 years is > = 10%: No = 0/Yes = 1).
��
Adjusted for educational status, household income, marital status, physical activity, sedentary time per day, fruits and vegetable consumption, current user of
smokeless tobacco, self-reported diabetes, and waist circumference (age, sex, smoking status, BMI, and hypertension were used to calculated CVD risk, i.e., the
outcome).
���
Never married, widows, divorced and separated.
����
Hindu, Christian, Buddhist, and others.
CI: Confidence Interval; COR: Crude Odds Ratio; AOR: Adjusted Odds Ratio; Ref: Reference category.
NA: Not applicable; these variables were not included in the adjusted analysis as these were dropped due to significance level was >0.2 in the crude analysis.

https://doi.org/10.1371/journal.pone.0251967.t003

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Table 4. Univariable and multivariable logistic regression results with potential determinants of elevated CVD risk �10% (for females)� .
Variables Univariable Logistic Regression Multivariable Logistic Regression��
COR 95% CI P value AOR 95% CI P-value
Place of residence
Rural Ref Ref
Non-slum urban 1.35 1.09, 1.67 0.006 1.08 0.84, 1.39 0.554
Slum 0.99 0.75, 1.29 0.912 0.66 0.49, 0.88 0.005
Educational status
No formal education Ref Ref
1–5 years 0.60 0.45, 0.81 0.001 0.68 0.50, 0.93 0.015
6–10 years 0.58 0.45, 0.74 <0.001 0.60 0.46, 0.79 <0.001
>10 years 0.28 0.16, 0.48 <0.001 0.33 0.18, 0.59 <0.001
Household income
Lowest (Q1) Ref Ref
Lower (Q2) 1.24 0.97, 1.60 0.090 1.15 0.88, 1.51 0.315
Middle (Q3) 1.31 1.03, 1.66 0.030 1.20 0.92, 1.56 0.170
Higher (Q4) 1.08 0.81, 1.45 0.593 1.05 0.77, 1.44 0.753
Highest(Q5) 1.17 0.91, 1.51 0.213 1.27 0.95, 1.69 0.108
Marital Status
Currently married Ref Ref
Others��� 5.11 4.24, 6.15 <0.001 3.96 3.26, 4.82 <0.001
Religion
Muslim Ref Ref
Others���� 1.27 1.01, 1.58 0.037 1.50 1.17, 1.92 0.001
Physical Activity
> = 150 Minutes/week Ref Ref
<150 Minutes/week 3.15 2.65, 3.75 <0.001 2.29 1.88, 2.78 <0.001
Sedentary time per day
< = 240 minutes Ref Ref
241 to 360 minutes 1.34 1.09, 1.65 0.006 1.12 0.89, 1.40 0.340
>360 minutes 1.83 1.48, 2.25 <0.001 1.22 0.97, 1.54 0.087
Fruits & Vegetables Consumption
> = 5 servings/day Ref Ref
<5 servings/day 1.54 1.11, 2.14 0.010 1.12 0.79, 1.60 0.517
Current smokeless tobacco user
No Ref Ref
Yes 1.30 1.10, 1.54 0.002 1.23 1.02, 1.48 0.032
Self-reported diabetes
No Ref Ref
Yes 1.49 1.18, 1.89 0.001 1.38 1.06, 1.80 0.016
Waist Circumference
Male: <90 cm/ Female: <80 cm Ref Ref
Male: > = 90 cm/ Female: > = 80 cm 1.04 0.88, 1.23 0.623 NA NA NA
�
The regression analysis outcome was elevated CVD risk (risk of CVD events in 10 years is > = 10%: No = 0/Yes = 1).
��
Adjusted for educational status, household income, marital status, physical activity, sedentary time per day, fruits and vegetable consumption, current user of
smokeless tobacco, self-reported diabetes (age, sex, smoking status, BMI, and hypertension were used to calculate CVD risk i.e., the outcome).
���
Never married, widows, divorced and separated.
����
Hindu, Christian, Buddhist, and others.
CI: Confidence Interval; COR: Crude Odds Ratio; AOR: Adjusted Odds Ratio; Ref: Reference category.
NA: Not applicable; these variables were not included in the adjusted analysis as these were dropped due to significance level was >0.2 in the crude analysis.

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

risk. Higher educational status was negatively associated with elevated CVD risk in both sexes
in multivariable logistic regression analysis.
Moreover, in the adjusted analysis, gradual decline of elevated CVD risk with the level of
education suggesting a dose-response relationship among males with aORs (95% CI): 0.89
(0.72–1.09), 0.79 (0.66–0.94), and 0.62 (0.50–0.78) and among females with aORs (95% CI):
0.68 (0.50–0.93), 0.60 (0.46–0.79) and 0.33 (0.18–0.59) for education levels ‘up to five years’,
‘ten years,’ and ‘more than ten years’, respectively, compared to the participants reporting no
formal education. Both males and females with insufficient physical activity had about two
times higher odds of having elevated CVD risk compared to those who were reportedly physi-
cally active. The odds of elevated CVD risk were threefold higher among males (aOR: 2.88,
95% CI: 2.00 to 4.14) and fourfold higher among females (aOR: 3.96, 95% CI: 3.26 to 4.82)
who were divorced, widowed, separated, or never married during the survey. Self-reported
diabetes also increased odds of elevated CVD risk by 1.5 times in males (95% CI: 1.21 to 1.98)
and 1.38 times in females (95% CI: 1.06 to 1.80). Moreover, females living in slums had lower
odds (aOR: 0.66, 95% CI: 0.49 to 0.88) of elevated CVD risk.

Discussion
There is evidence that in most cases, CVD events such as myocardial infarction, stroke do not
occur due to a single risk factor. Instead, it precipitates from the holistic effect of multiple risk
factors [22]. In general, the evaluation of cardiovascular disease risk by general physicians is
limited [23]. In this study, we aimed to estimate the 10-years risk of fatal or non-fatal CVD
events among the males and females of Bangladesh by using the WHO non-laboratory-based
CVD risk chart. To the best of our knowledge, this is the first study in Bangladesh, in which we
calculated CVD risk with nationally representative data. We found that 27.5% of the study
population (aged 40 to 74 years), i.e., one in every four participants, had elevated risk (CVD
risk �10%) of a fatal or non-fatal CVD events in the next 10 years of the survey [Fig 2]. This
prevalence of CVD risk is higher than a previous study in Bangladesh carried out by Fatema.
et al., in which the rate was 20.2% [9]. Another South Indian study reported the rate as 14%
[22]. The possible reason might be that both of these studies were conducted in rural areas in
2011–2012 and the difference in age ranges (31–74 years in Fatema. Et al.). Another cross-sec-
tional study in Nepal also reported a lower proportion (13.6%) of elevated CVD risk though
the study was not nationally representative [24]. In our study, the proportion of the population
with a high to very high risk of CVD (CVD risk �20%) was 1.7%. This proportion was much
lower than the findings from other studies in Bangladesh (11%) [9], Nepal (4.3%) [24], rural
south India (male 4.5% and female 5.3%) [22]. The lower proportion of high to very high CVD
risk in our study might be due to the difference between the charts we used and is in alignment
with the recommendations of the WHO CVD Risk Chart Working Group who reported mod-
erate agreement between risk predictions using laboratory and non-laboratory based charts
[10]. Despite this limitation of the non-laboratory-based chart, we can say that in the areas
where laboratory testing is not convenient or unavailable, this low-cost, low-skill approach can
simplify the CVD risk assessment of the people aged 40–74 years.
In this population, elevated CVD risk was higher among males than females (p <0.001).
While about 31% of the males were in the moderate risk category, this proportion was about
20% in the case of females. The proportion of males in the high to the very high-risk category
(CVD risk �20%) was three times higher compared to females. This sex difference in the prev-
alence of CVD risk is also evident in other studies [22,24]. However, in contrast to our find-
ings, at least one study reported mixed findings, i.e., males had a higher proportion in the
moderate-risk group whereas, in the high-risk group, females were in a higher proportion [9].

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

This difference may be due to the cause that men are at risk of developing cardiovascular dis-
eases 7 to 10 years earlier compared to women [25]. Moreover, the effect of endogenous estro-
gen during the reproductive period delays the onset of CVD in women [25]. Evidence from
the Women’s Ischemia Syndrome Evaluation (WISE) study showed that the risk of coronary
arterial diseases is sevenfold higher in women with endogenous estrogen deficiency [26].
CVD risk was negatively associated with the education level among males and females. For
those with more than 10 years of education, the odds of elevated CVD risk (CVD risk �10%)
were lower by one-third in males and two-thirds in females than those with no formal educa-
tion. Studies in Nepal [24] and Austria [27] found similar associations between education level
and elevated CVD risk. Education might be a determining factor in lifestyle modification [28].
A study from Chicago, IL, USA, reported that knowledge of risk factors could motivate people
to change their risky behavior [29]. In our study, marital status was also found associated with
elevated CVD risk. Those who were divorced, separated, widowed, or never married during
the interview had higher odds of elevated CVD risk in 10 years. Findings from a prospective
cohort study also suggest the same [30]. Divorced, separated, widowed, or never-married per-
sons may have reduced social support and reduced motivation to lead an active and healthy
lifestyle [30].
Physical inactivity, smokeless tobacco use were also found associated with higher odds of
elevated CVD risk among both sexes in this population. However, high household income and
high sedentary time were significantly associated with CVD risk only among males. These are
established risk factors of cardiovascular diseases, and these findings are consistent with sev-
eral studies in Bangladesh and elsewhere [1,31]. Insufficient physical activity and other behav-
ioral and clinical risk factors of NCDs, including overweight, high blood pressure, tobacco,
and high blood sugar levels, are interrelated and can influence each other [7].
The use of the WHO non-laboratory-based CVD risk prediction chart can help in the early
detection of individuals with an elevated or high to very high risk of having fatal or non-fatal
CVD events and can supplement the prevention and management programs of CVD in
resource-poor settings. It can be useful, especially in resource-poor settings, where the health
facilities are not equipped to detect blood sugar, and serum cholesterol levels as the WHO lab-
oratory-based CVD risk chart needs these data. Prediction of CVD risk using the non-labora-
tory-based chart can also reduce the proportion of population needing pharmacological
intervention as the people with low to moderate risk of CVD can be managed by an integrated
approach to lifestyle changes regular follow-up. Health care professionals, particularly those
working in the primary health care system in resource-poor settings, should be trained on this
chart so that they can contribute to the prevention and control of CVD and related diseases by
implementing screening, counseling, management, and referral.

Strengths and limitations

In Bangladesh, few studies have reported the CVD risk based on the WHO CVD risk chart.
However, to the best of our knowledge, this is the first-ever study in Bangladesh reporting
CVD risk using the non-laboratory-based WHO CVD chart as well as using nationally repre-
sentative data. Our study also had some limitations, and one of them is sampling challenges
during the implementation of the study. We had to drop seven pre-selected rural clusters due
to administrative and financial constraints, which might affect the overall representativeness
of the study. To calculate the CVD risk using the aforementioned chart, one needs to drop the
participants if s/he has a history of CVD events such as heart attack or stroke. In our study,
although we have collected data on the history of heart diseases, data on the history of myocar-
dial infarction (MI) or heart attack could not be separated from that. So, we only dropped the

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

participants who had a history of stroke but could not drop those who had a history of MI or
heart attack, which might have influenced the prevalence of elevated CVD risk. Also, this is a
cross-sectional study, and therefore, the temporality of the associations revealed in this study
cannot be established. To include the highest number of cases in this analysis, we imputed miss-
ing values for specific variables. Besides, due to lack of data, some possible confounders such as
salt consumption, genetic factors, family history could not be taken into account. We, therefore,
emphasize the importance of further research on the determinants of elevated CVD risk in this
population using both laboratory-based and non-laboratory-based CVD risk charts.

Conclusion
One in every four Bangladeshi adults had elevated levels of CVD risk, and males are at higher
risk of experiencing CVD events. Non-laboratory-based risk prediction charts can be effec-
tively used in low resource settings in Bangladesh and elsewhere. The government of Bangla-
desh should train the primary health care workers on the use of non-laboratory-based charts,
relevant control, and management options in places where laboratory tests are not available.

Supporting information
S1 Table. Complete case analysis: Univariable and multivariable logistic regression results
with potential determinants of elevated CVD risk �10% (for males).
(DOCX)
S2 Table. Complete case analysis: Univariable and multivariable logistic regression results
with potential determinants of elevated CVD risk �10% (for females).
(DOCX)
S1 Data. Dataset in Stata format. This is the final dataset we used to produce all the tables
and figures used in the manuscript.
(DTA)
S1 File. Questionnaire in English language.
(PDF)
S2 File. Questionnaire in Bengali language.
(PDF)

Acknowledgments
We acknowledge all the participants of the study and their family members, Research Assis-
tants, Field Supervisors, community leaders, all the administrative and accounts staff of the
BRAC James P Grant School of Public Health and Institute of Public Health and Nutrition,
members of the Technical Advisory Committee, and the local administrators for their support
during this work.

Author Contributions
Conceptualization: Abu Abdullah Mohammad Hanif.
Data curation: Abu Abdullah Mohammad Hanif, Md. Mokbul Hossain.
Formal analysis: Abu Abdullah Mohammad Hanif.
Funding acquisition: Malay Kanti Mridha.

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PLOS ONE Cardiovascular disease risk among the Bangladeshi population

Investigation: Mehedi Hasan, Md Showkat Ali Khan, Abu Ahmed Shamim, Samir Kanti Sar-
ker, Dipak Kumar Mitra, Malay Kanti Mridha.
Methodology: Mehedi Hasan, Md Showkat Ali Khan, Abu Ahmed Shamim, Samir Kanti Sar-
ker, Dipak Kumar Mitra, Malay Kanti Mridha.
Project administration: Abu Abdullah Mohammad Hanif, Mehedi Hasan, Md Showkat Ali
Khan, Md. Mokbul Hossain, Moyazzam Hossaine, Mohammad Aman Ullah, Samir Kanti
Sarker, S. M Mustafizur Rahman, Md Mofijul Islam Bulbul, Malay Kanti Mridha.
Resources: S. M Mustafizur Rahman.
Supervision: Abu Abdullah Mohammad Hanif, Md Showkat Ali Khan, Md. Mokbul Hossain,
Moyazzam Hossaine.
Writing – original draft: Abu Abdullah Mohammad Hanif.
Writing – review & editing: Abu Abdullah Mohammad Hanif, Mehedi Hasan, Malay Kanti
Mridha.

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